Penile fracture is a rare emergent condition, which includes rupture of the tunica albuginea of corpus cavernosum that occurs after trauma to the erect penis. The true incidence of penile fracture is not known as it is rare and under reported entity. Bilateral rupture of tunica albuginea with complete urethral disruption is very rare and very few cases were reported. We report a case of a 46-year-old man who presented with acute pain and swelling of penis and hematuria and severe burning pain during micturition, after a blunt trauma during sexual intercourse. Magnetic resonance imaging (MRI) revealed bilateral rupture in tunica albuginea and complete urethral disruption. We have done emergency repair of tunica and urethra suturing over a catheter. Postoperatively, patient regained normal erectile and voiding functions.

Penile fracture is a surgical emergency and it is the rupture of the tunica albuginea secondary to trauma to the erect penis. The true incidence of penile fracture is not known as it is under reported because of social embracement. [1],[2] Penile fracture is an entity of clinical diagnosis. Nevertheless, magnetic resonance imaging (MRI) is indicated in doubtful cases. Immediate surgery is needed in order to prevent postoperative complications like erectile failure and curvature. We report a case of bilateral rupture of tunica albuginea with complete urethral disruption after a blunt trauma during sexual intercourse.

Case Report

A 46-year-old man reported to the emergency department with acute pain, swelling, and detumescence of penis after blunt injury during sexual intercourse. There was a history of hematuria and difficulty in voiding and severe burning pain during micturition. Physical examination revealed an edematous, ecchymotic, deformed penis, with urethral bleeding [Figure 1]. MRI revealed bilateral rupture in tunica albuginea and complete urethral disruption [Figure 2]. After circumferential sub coronal degloving incision, hematoma was evacuated and a bilateral tear of the tunica albuginea with complete urethral disruption was noted [Figure 3]. Tunica laceration was closed with interrupted 3/0 vicryl. The urethra was spatulated and anastomosed with 3/0 vicryl after stenting over a 16-F catheter [Figure 4]. Patient was given intravenous antibiotics for 3 days and catheter was removed after 3 weeks. Postoperatively, patient regained normal erectile and voiding functions.

Tunica albuginea becomes as thin as 0.25-0.5mm when the penis is erect and it is up to 2-2.5mm thick, while in the flaccid state. [2],[3] Increased intracavernosal pressure with buckling of tunica albuginea leads to rupture of thinned out tunica. Patients with penile fractures are usually present with a typical history of snapping sound as the tunica tears due to blunt injury at the time of inter course , followed by acute swelling and pain, and rapid deformity and detumescence. [2],[4] "Eggplant deformity" [penile hematoma confined within skin and tunica when bucks fascia remains intact] [5],[6] and "butterfly sign" [diffuse hematoma of scrotum and perineum when bucks fascia is disrupted] are important clinical signs for diagnosing this condition. [3],[6] The "rolling sign" is a firm, immobile hematoma, palpable beneath the penile skin when it is rolled over it. [3],[5]

Penile rupture can be diagnosed based solely on clinical findings. However, cavernosography or MRI is advocated in equivocal cases. [2],[7],[8],[9],[10] As the conservative management has higher complication rates, surgical repair is now the gold standard for treatment of penile fracture. [11],[12] Surgery consists of complete evacuation of the hematoma, and repair of the tear with absorbable sutures in the tunica albuginea. A subcoronal, circumferential incision exposes all three corporeal compartments, which is useful for exploration and repair of any concomitant urethral injury. Immediate surgical repair has been associated with improved outcomes including decreased incidence of erectile dysfunction. [2],[5]

The incidence of associated urethral injuries is between 10% and 22% of reported cases. [2] Blood at the meatus, an inability to void, or hematuria is the signs of urethral injury. Patients with bilateral corporeal rupture should be suspected to have urethral injury. [5] Retrograde urethrography is advocated in any case of penile fracture when there is suspicion of associated urethral injury. [2],[4],[5] Partial urethral tears can be treated by urethral catheterization, primary closure, or suprapubic cystostomy. Complete urethral injuries can be managed with primary reanastamosis, graft interposition, or stenting over a urethral catheter. [13]

Postoperatively, patients should be counseled to abstain from sexual activity for a period of at least 6-8 weeks. [14] They should also be counseled for complications like erectile dysfunction, penile curvature, and urethral fistula. Penile curvature is present in 5% of cases and occurs in patients with a delayed presentation. [1]

In conclusion, penile fracture can be diagnosed by clinical findings. Whereas, in equivocal cases, cavernosography or MRI should be performed. Retrograde urethrography is indicated when patient has voiding symptoms. Emergency surgical repair can preserve erectile and voiding function.